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Lower Extremity Amputation and Prosthetic Rehabilitation

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Lower Extremity Amputation and Prosthetic Rehabilitation Describe the VA Amputation System of Care and why it was developed . Identify and describe the phases of rehabilitation care in the Clinical Practice Guideline for the Rehabilitation of Lower Limb Amputation . Describe evidenced-based prosthetic and amputation rehabilitation outcomes . Understand the importance of good working relationship between a physical therapist and Prosthetist . Identify appropriate fit of lower extremity prostheses . Describe how the information gained during the lecture can be applied to your clinical practice . Each major military operation has resulted in a new cohort of veteran’s with combat-related traumatic amputation: . Civil War 70,000 . WW1 4,403 . WW2 14,912 . Korea 1,000 . Vietnam 5283 . Persian Gulf War 15 . OIF/OEF /OND 1643 . DoD identified a need for the combat-injured soldier with major traumatic limb loss . 1st Military Treatment Facility (MTF) for Soldier Amputees created at Walter Reed Hospital . 2006 –VA collaborates with DoD to meet the needs of these newly combat-injured vets from OIF/OEF while also improving care to all vets with amputations due to medical issues . June 2008, Dept of VA Health Systems Committee approved the development of the ASoC and was implemented in FY 2009. Specialized expertise in amputation care . Medical rehab, therapy, prosthetic technology . Multidisciplinary approach . Enhance environment of care and ensure consistency . VISION - Be a world leader in providing lifelong amputation care Regional Amputation Centers – RACs (7) Medical Director Amputation Rehabilitation Coordinator Program Support Assistant RAC Prosthetist Polytrauma Amputation Network Sites – PANS (18) Medical Director 0.5 Amputation Rehabilitation Coordinator Program Support Assistant Amputation Clinic Teams – ACTs (108) Amputation Points of Contact - APOCs (22) . PANS-Indianapolis . Core Interdisciplinary Amputation Care Team(MD, Prosthetist/Orthotist, PT,OT, & Psychologist) . Regularly scheduled Amputee Clinic . Clinical Video Tele-amputee Clinics with RACs, ACTs, APOC,CBOCs . Accredited Prosthetics Lab . 2016 CARF Amputation Specialty Program Accreditation - Inpatient and Outpatient . Peer Visitation Program 2010 . VET PALS Research (2014) . Data collection/ Outcomes Measures • Amputation Data Registry / Repository • Clinical Practice Guideline following Upper and Lower Limb Amputation . Structured document that provides health care practitioners with recommendations for various related health outcomes: . Postoperative pain . Physical Health . Function . Psychological support & Well-Being . Patient Satisfaction . Reintegration . Healthcare Utilization . Improve patient care by reducing variation in practice . Systematizing best practices to achieve best outcomes . Adult patients with major lower extremity amputation (bilateral and unilateral) including through-hip, transfemoral, through-knee, transtibial, through-ankle, and partial foot. Cause may be traumatic or non- traumatic. In 2014, 2.1 million people were living with limb loss in the US. By 2050, that rate is expected to double to 3.6 million . Common Causes of LE Amputation . Dysvascular (54%) – Peripheral Vascular Disease, Diabetes Mellitus, Chronic Venous Insufficiency . Trauma (45%) . Cancer and Malignancies (2%) (Us Dept Health and Human Services) . Diabetes affects 25.8 million people in the US and 189 million people worldwide. By the year 2025 the prevalence of diabetes is expected to rise by 72% to 324 million people globally. (American Diabetes Association) . Up to 25% of those with diabetes will develop a foot ulcer. (Singh, Armstrong, Lipsky. J Amer Med Assoc 2005) . >50% of all foot ulcers (wounds) will become infected, requiring hospitalization and 1 in 5 will require an amputation. (Lavery, Armstrong, et al. Diabetes Care 2006) . Other risk factors for amputation - PAD, LOPS, insulin dependence, impaired glucose control (Selby and Zhang, Diabetes Care 1995) . Ambulatory mobility declined during the period immediately prior to surgery (premorbid) and remained low at 6 weeks post surgery. On average, ambulation improved after surgery up to one year but did not return to premorbid levels … (Czerniecki et al, Archives of Physical Med and Rehab 2012) . Center for Disease Control and Prevention have suggested the following: . declines in diabetic amputation rates can be attributed to improvements in preventive care (appropriate footwear and patient education) . PAVE – Prevention of Amputations in Veterans Everywhere . LEAP - Lower Extremity Amputation Prevention . Dept of Health and Human Services Health Resources and Services Administration . http://www.hrsa.gov/hansensdisease/leap/ . PAVE committee developed with VHA directive and recommends: - Daily self inspections - Annual foot exams - High Risk Level Exams - Proper fitted shoes The continuum of Amputee Care is divided into 5 Specific Phases: . Pre-operative Phase . Post-operative Phase . Pre-Prosthetic Phase . Prosthetic Training Phase . Long Term Follow-up Phase . Decision to amputate . Assess functional status and health . Consideration of amputation level, pre- op education, emotional support, physical therapy, nutritional support, pain management . Patient Education . Learning Assessment- tailor education to meet needs of the individual with limb loss and identify barriers . In-depth education to patient and family regarding the procedure, various components of postoperative care, and rehabilitation activities that will occur . Patients should be given appropriate advice and information on rehabilitation programs, prosthetic options, and possible outcomes with realistic rehabilitation goals (Esquenzai & Meier, 1996; Pandian & Kowalske, 1995). VA and Amputee Coalition Materials: 1. The Next Step: The Rehabilitation Journey After Lower Limb Amputation 2. The First Step: A Guide for Adapting to Limb Loss 3. Side Step: A Guide to Preventing and Managing Diabetes and its Complications • VA Amputation Education Support Group –Amputee Rehab Coordinator, Certified Peer Visitors, Rehab Psychology, Amputee Clinic Evaluation with team • Tobacco cessation, coping strategies, support resources, contracture prevention, skin inspection and care, desensitization techniques, shrinker/RRD care, sound limb protection • Review of the literature suggest that psychological intervention during the preoperative period is associated with a less complicated postoperative adjustment and grieving experience (Butler et al., 1992) . Initiate Appropriate Rehabilitation Interventions . Cardiovascular Fitness and Endurance . Balance . Strength/ROM –Assess for contractures . Sensation . Functional Rehab ( ADL, Transfers, Mobility, DME) . Time in hospital after amputation surgery, lasting 5-14 days. Hemodynamic stability, wound healing, prevention of complications . Care of residual limb, patient education, physical therapy, occupational therapy, behavioral health . PT’s-Baseline fxn . Post-op Dressings . Soft Dressings vs. Rigid Dressing . Soft Dressings: ACE Wrap, Shrinkers, Compression Pump . Rigid Dressings: NWB rigid dressing, IPOP, Custom removable rigid dressing ( RRD), Prefabricated RRD, Prefabricated pneumatic IPOP . Limited evidence is available regarding the management of residual limb volume and what there is focuses primarily on adults with transtibial amputation in the early postoperative phase (Sanders et.al., 2011) . Residual Limb Management – encourage patient participation . Reduce post-op edema , begin shaping limb with compression, promote incision healing . RRD, Shrinker . Protect residual limb from trauma . RRD for BKA • Mirror therapy . Mirror therapy . Protocol= 15 minutes/day, 4 weeks . 18 patients ; six in each of the following: Mirror therapy group, covered mirror therapy group, mental imagery group . Mirror therapy group (all 6) reported decreased phantom limb pain; 1 in covered mirror and 2 in mental imagery reported decrease as well; 7 reported increase in phantom limb pain (Chan et al., 2007) . 9/12 not assigned to mirror therapy group began 4 week mirror therapy tx and all but 1 reported decrease in pain . Repeated exposure to virtual images of mirror box may be necessary to improve likelihood of reducing phantom limb pain sxs . Focus on Residual Limb Management : volume reduction, pain control, contracture prevention . Continued patient and family education . Continued coping with loss of a limb . Discharge planning from Acute Care . Patient avoids looking at or talking about amputation. Tearfulness (this doesn’t always indicate depression but instead maybe more of an adjustment issue) . Disparaging/negative remarks about him/herself (could be body image related) . Change in behavior or mood/demeanor . Consult to Rehabilitation Psychologist/Behavioral Health Specialist Not for Profit organization on limb loss, dedicated to enhancing the quality of life for amputees and their families, improving patient care and preventing limb loss Working to ensure that no amputee goes through their journey alone Peer Visitor Program inception 2003 to support wounded warriors at Military Hospitals . Partnered with the VA to implement Certified Peer Visitor Training Programs throughout the ASoC in 2010 and PALS (Promoting Amputee Life Skills) programs in 2012 . Provide Educational materials ( online and hard copy) . Limb Loss Education Days and National Conference . Peer visitation of the amputee patient allows the patient to speak directly with another amputee who has shared a similar experience, which enables the patient to share feelings and concerns about the
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